This application is for a three-year electronic health record implementation and evaluation project led by Hancock County Memorial Hospital and eight additional small rural hospitals in north Iowa in partnership with Mercy Medical Center-North Iowa, Trinity Health, and the University of Iowa Department of Health Management and Policy. These partners will combine clinical and technical expertise as well as financial resources to make it possible for these very small rural health care organizations and their 24 affiliated primary care clinics to successfully implement a highly sophisticated, comprehensive EHR system with computerized physician order entry, evidence-based care guidelines, decision support tools, and a full suite of revenue cycle products. These new interoperable EHR technologies will be accessible to authorized providers whenever and wherever they care for patients. The project has four major goals: 1) to increase standard evidence-based care practices throughout the implementing partners, 2) to enhance the abilities of providers to coordinate patient care across the network and beyond, 3) to maximize use of clinical expertise and learning within and across their organizations, and 4) to produce significant, measurable, and sustainable improvements in patient safety and quality of care, as well as increased organizational and financial efficiencies. The major evaluation dimensions to be studied by the University of Iowa are: A) changes in patient care delivery, B) changes in quality, patient safety and access to specialty consultation, C) changes in staff and physician perceptions of quality and safety, and D) organizational learning. The specific dimensions to be studied within these areas are: i) the leadership strategies for hospital security levels used in the EHR/COE implementation; ii) how the common integrated role-based work flow processes, clinical decision support rules, and condition of service-specified evidence-based order sets change patient care processes; iii) changes in staff and physician perceptions of quality, safety, and specific indicators used to assess patient care quality and safety as a result of the implementation; iv) how access and relationships among the nine hospitals, MMC-NI, and visiting specialists are affected; v) how job satisfaction, work tasks, and adverse event and error reporting are affected, and vi) how an EHR/CPOE implementation influences organizational learning within individual hospitals and a multi-hospital network. [unreadable] [unreadable] [unreadable]